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Initial Burn Care

Initial Burn Care. Lee D. Faucher, MD FACS Director UW Burn Center Associate Professor of Surgery & Pediatrics. Objectives. Discuss burn pathophysiology Outline treatment modalities Understand why some treatments better than others. What is a burn?.

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Initial Burn Care

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  1. Initial Burn Care Lee D. Faucher, MD FACS Director UW Burn Center Associate Professor of Surgery & Pediatrics

  2. Objectives • Discuss burn pathophysiology • Outline treatment modalities • Understand why some treatments better than others

  3. What is a burn? • Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

  4. First Degree Burns • Epidermis only • No blisters • Erythema • Mild to absent systemic response • Heals in 3-4 days

  5. Superficial partial thickness • Papillary dermis • Blisters • Homogenous pink • Painful, hypersensitive • Blanches • Hair usually intact • Does not scar, may pigment differently

  6. Sup 2nd degree

  7. Deep partial thickness • Reticular dermis • Mottled red and white • Not painful to pinprick or pressure • Does not blanch • Heals > 3 weeks • Usually scars • Need to excise and graft

  8. Deep dermal

  9. Full thickness burns • Into fat or deeper • Red, white, brown, black, etc. • Diminished sensation • Dry, may be leathery • Depressed • Heals only from the periphery • Always excise and graft

  10. Full-thickness

  11. Etiology

  12. Types of burns

  13. Where do burns occur

  14. Circumstances of injury

  15. Admissions by age

  16. % of admissions vs. burn size

  17. Inhalation injury diagnosis • Closed-space fire • Face burns

  18. Terminology • Inhalation injury “nonspecific” • Thermal injury • Upper airway • Local chemical irritation • Throughout airway • Systemic toxicity • CO

  19. History and physical Exposure Duration Enclosed space Diagnostic studies Clinical diagnosis

  20. Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea Other signs and symptoms

  21. Poison management = CO • 500 unintentional deaths each year • Persistent Neurologic Sequelae • May improve over time • Delayed Neurologic Sequelae • Relapse later

  22. Poison management = CO • Treatment • CO level means nothing to predict outcome • Length of hypoxia is the determining factor • Oxygen • HBO • No studies show benefit in treatment

  23. Pathophysiology • The main factor responsible for mortality in thermally injured patients • Carbon monoxide the most common toxin • 200 times greater affinity • Competitive inhibition with cytochrome P-450

  24. Reduction of CO

  25. Objective data • Bronchoscopy • Edema • Infraglottic soot • Hyperemia • Mucosal sloughing • Sensitivity near 100% under IDEAL circumstances

  26. Grading of injury • No reliable indicators of progressive respiratory failures • No studies have found any correlation with initial findings and clinical outcomes and progress

  27. Resuscitation

  28. Field resuscitation • Start IV with LR, in burn OK • < 6 years = 125mL/hr • 6-13 years = 250mL/hr • >13 years = 500mL/hr

  29. Rule of Nines

  30. Lund and Browder Chart

  31. IV access • < 15% TBSA – oral resuscitation • 15 – 40% TBSA – one large bore IV • > 40% -- two large bore IV’s • IV’s should be in the upper extremities • Suture IV’s started through burns

  32. Crystalloid solution • Ringer’s Lactate • [Na+] 130 mEq (serum 140 mEq) • Osmolality 272 mOsm (serum 300mOsm) • Advantages of crystalloid • Effective in maintaining perfusion • Costs less than colloids • Can be mobilized with a diuretic

  33. Resuscitation first 24 hours • Baxter formula • 4 mL/kg/% TBSA burned • Give ½ the volume in first 8 hours and other ½ over next 16 hours.

  34. If < 20kg • Same Baxter formula for LR • Add 4mL/kg of D5 ¼ NS • Infuse at constant rate, increase LR if needed for adequate urine output

  35. Monitor urine output • Place foley if > 20% TBSA • Urine output goal • 2 mL/kg/hr very young • 1 mL/kg/hr child • 0.5 mL/kg/hr adult • Diuretics are NEVER used to increase urine output • Increase urine output to > 100mL/hr if pigment present

  36. How to do this • Maintain continuous IV fluid replacements • AVOID boluses • Only bolus IV fluids if hypotensive

  37. Zones of burn injury

  38. Pain control

  39. Non-medication methods • Cover burns with plastic wrap • Wet dressings will stick and cause more pain • Other burn dressings are expensive and not necessary • Quik Clot is expensive and will not provide any patient benefit

  40. Ice Pack-----DO NOT USE EVER • DOES NOT • Reverse temperature • Inhibit destruction • Prevent edema • DOES • Delay edema • Reduce pain

  41. Medication • Medications • Opioids • Narcotics • Pain medications • IV Analgesia

  42. Summary • Airway • Circulation/Resuscitation • Pain control

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